Memorial Planning Guide

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1 Memorial Planning Guide A precious gift Providing your family with thoughtful guidance at an emotionally stressful time, is the most precious gift you can give them. Cournoyer Funeral Home & Cremation Center

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3 Memorial Planning Guide The death a family member causes one the most emotionally stressful times we must endure in our lives. Please help us assist your family by taking the time to provide the information requested in this guide. By relieving your family the burdens having to find this information on their own, and by making these decisions for them now, you will have given them a lasting and very precious gift. Personal Information Your First, Middle and Maiden Last Name: Current Address (street & number) Town County State Date Birth: Place Birth: Citizen Social Security # Telephone # address: Primary Doctor s Name: Office Location: Additional Doctor s Names: Mother's First, Middle and Maiden Last Name: Place Her Birth: Father's First, Middle and Last Name: Place His Birth: Marital Status: (check one) Single / Never Married Married Separated Divorced Widowed Spouse s First, Middle and Maiden Last Name: Date Married: Place Married: Spouse s Date Death: (if applicable) Additional Marital Information: Education: Highest Grade school completed: High School attended: Year Graduation: College/s attended: Degrees Earned: Graduate School/s attended: Military Information** Branch Service: Service Number: Rate or Rank at Discharge: Enlistment date and place: Discharge date and place: Wars / Locations Served in: **A photocopy your DD214 must accompany these notes. Copy enclosed Yes No

4 Personal History for an Obituary Places Lived: (Towns/Cities, States and years lived there) Occupation: Positions Held: Retirement Year: Employer/s & Locations: Clubs, Lodges, Memberships, Church & Public Office held: Hobbies / Interests: Other Information: (Predeceased by, etc.) ~ Please list all Surviving Relatives with their Town/City and State Residence ~ Father: Mother: Spouse: years, Daughters: Sons: Brothers: Sisters: # Grandchildren # Great Grandchildren # Great Great Grandchildren # Step-Grandchildren # Step-Great Grandchildren Nieces/Nephews/Cousins Y / N

5 Additional Family History: I would like Memorial Donations to go to: I have enclosed a Photograph myself: Yes No Use the Photograph for my Obituary? Yes No I would like my Obituary / Death Notice placed in the following newspapers: Keene Sentinel Monadnock Ledger-Transcript Union Leader Gardner News Athol Daily News Worcester Telegram Fitchburg Sentinel Milford Cabinet Nashua Telegraph Concord Monitor Fosters Daily Democrat Laconia Citizen Lowell Sun Lawrence Eagle-Tribune Boston Globe Other Newspapers Personal Wishes and Information for Funeral Arrangements Birthdays are celebrated every year a celebration life occurs only once. Your choices should reflect your exact personal wishes and will allow friends and loved ones to express their love with a ceremony that is as unique as you are. Person to be in charge my funeral arrangements: Name: Address Telephone # s (home) (work) (cell) I prefer: Burial Cremation If Cremation, Before Services After Services Are Calling Hours to be held? Yes No If yes, where are the Calling Hours to be held? At the funeral home At my residence At another location (Describe) Open to the Public Private Calling Hours for my family only Preferred Times: ~ Casket Present? Yes No If yes, Open Casket? Yes No Urn Present? Yes No Casket Preference Metal Wood (Describe) Personalization (Cap Panel, Keepsake Corners, Engraving, etc.) Vault Preference Urn Preference Keepsakes Prayer Card Preference Style: Prayer: Clothing & Jewelry Preferences: Flower requests

6 I would like the following Personal Items displayed at Calling Hours: I would like: Computer / Photo Slide Show Photo Collage Boards Webcast Services I would prefer a: Standard Hearse Tombstone Motorcycle Hearse Military Hearse F350 Family Hearse Other Antique Hearse (Describe) Horse-drawn Hearse Other (Describe) I would prefer the following Pallbearers: I would like my Funeral or Memorial Service to be conducted at: The funeral home The graveside At my church At another location (Describe) Preferred Clergy Favorite Bible Passages, Readings, Poetry, Quotations and Verses, Etc. Organist Soloist Favorite Hymns, or Special Song Requests Other Music Requests (Bagpipes, etc.) Military Honors: Yes No Bugler Yes No Flag Presentation Yes No Firing Squad Yes No Participating Pressional / Fraternal Organizations: (Fire Department, Rotary International, etc.) I would like my family to have a catered reception after my Funeral or Memorial Service. Yes No Where Preferred Caterer Meal Do you have additional ideas or suggestions that would help make your service more meaningful? Are there any other Final Arrangements that you have made or prepaid that you would like your family to know about?

7 Cemetery Information and Instructions Cemetery Name: Location Cemetery Lot # Section In whose Name is the Lot registered? Where in Lot is grave to be opened? Grave # Is a Grave Marker already installed? Yes No (Describe) Do the dates need to be engraved? Yes No If Yes, the entire date? (January 1, 2010) or year only? (2010) Additional Cemetery Information: If a cemetery setting is not desired after Cremation, please describe your preferences for what should happen to the cremated remains: Pets have special meaning in our lives. Are there any special requests or instructions regarding the care your pets after your death? Additional Notes, Information, or Instructions

8 Please use this space for any additional notes, drawings or diagrams. Cournoyer Funeral Home & Cremation Center Thirty-Three River Street Post Office Box 486 Jaffrey, New Hampshire Independently owned and operated by the Cournoyer Family since 1915 Tel: 603~532~6484 Fax: 603~532~5725

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